After completing my dermatology residency training and passing the board examination in 1991, I started my own private practice. Aside from the usual logistical issues, such as finding a physical space, hiring staff, and ordering all the usual medical supplies, my biggest concern was to be sure that I had enough patients and that I would provide competent care and, true to our oath, first do no harm. Times were relatively simple- no computers, no social media, no online reviews, no electronic health records, no Dr. Google, no information overload and all the other things that in some ways have interfered with the physician-patient relationship.
Armed with years of training and knowledge, I felt relatively confident that my practice would blossom and that I would be able to build long-term relationships with my patients, which I am happy to report, is what happened. That said, a successful practice in no way implies that all patients experience improvement, and when a patient’s acne, psoriasis, melasma or other chronic condition fails to improve, it’s tempting to attribute a suboptimal outcome to patient noncompliance. After all, studies have shown that one in three medication prescriptions are never filled, and that as many as 40% of patients fail to adhere to a treatment regimen, with that number climbing to 50% for those with chronic conditions lasting 6 months or more. With experience, I have learned that it is far more productive to understand the reasons for noncompliance or failure to adhere to a regimen than to blame the patient.
As physicians, we have the “disease to please” combined with a need for measureable success, both of which are arguably validated by improvement in a patient’s condition. When a patient fails to follow a treatment regimen, it is very helpful to understand why. Studies have shown that three factors influence patient compliance: 1) health care-related factors, such as the patient- physician/heath care provider relationship; 2) patient-related factors, such as disease severity, level of understanding, and existing comorbidities; and 3) therapy-related factors, including complexity of the regimen and duration of treatment. The reality is that each of these factors is intricately related to the others, and the best way to ensure patient adherence is to keep some simple things in mind.
Create a partnership with the patient
It seems obvious, but a healthy patient-physician relationship is based on trust, collaboration, and understanding. In today’s environment of declining reimbursements and escalating practice costs, we find ourselves seeing more and more patients, which means less time spent with each patient. Greeting the patient goes a long way to enhance the patient-physician relationship, and everyone in your practice should be courteous and genuinely glad to see the patient. We are here to serve them – not the other way around. During the actual visit, listen and do not interrupt the patient. We are often rushed, but the patient has typically been waiting weeks to months for the opportunity to see you.
Acknowledge the patient’s concerns, be honest, allow time for questions, and provide the means for keeping communication open between appointments. I have found it helpful to create business cards for everyone in my practice, including administrative and clinical staff. I ask the medical assistant who was with me during the visit to give the patient her/his card for 2 reasons: to create a contact team member for that patient, and to ensure accountability of the staff member in responding to patient communications, whether by phone or e-mail.
When I am running late, which is more often than not, I go into the exam room and let the patient know that I am aware that she/he has been waiting, apologize, and acknowledge that her/his time is valuable. At the start of the encounter, I ask the patient what he or she wants to accomplish during the visit, which is very helpful in then setting expectations. At the end of the visit I always thank the patient for their trust and for choosing me as their physician.
Empower the patient through education
We all know that patients often research their symptoms and may or may not have come up with the correct diagnosis. Rather than reprimanding the patient for “playing doctor,” I make a lighthearted remark to the effect that it’s great to have access to Dr. Google, who has no wait time and works 24/7 and compliment the patient for being proactive in their well being. This allows me to educate the patient regarding the actual diagnosis. The amount of information a patient receives correlates with the perception of active participation in her/his care. Greater involvement and participation in her/his care will translate to greater adherence to the treatment regimen.
No pun intended, but my goal is for patients to have “skin in the game,” by which I mean making patients feel motivated to manage their conditions. Empowering a patient through education allows her/him to apply a skill set or to learn a new set of skills required to take care of her/his specific skin condition.
In Part 2 of this series, Dr. Vivian Bucay will share additional advice on enhancing patient compliance. Check back to learn more on this important subject from this well-known thought leader in the field of dermatology.